••• CHAPTER 32^ Hysterectomy^305
❍ When is hysterectomy indicated in the treatment of leiomyomata uteri?
If the patient has no symptoms, treatment can often be expectant. In women who have completed their
childbearing and who have symptoms related to myomas, hysterectomy represents the definitive cure.
❍ What are the ACOG guidelines for hysterectomy for leiomyomata?
(1) Asymptomatic, but abdominally palpable, and of concern to the patient or
(2) Excessive uterine bleeding: With evidence of profuse bleeding with flooding/clots or repetitive periods lasting
8 days, or anemia or
(3) Pelvic discomfort: Acute and severe, chronic lower abdominal pain or low back pressure or bladder pressure
with urinary frequency.
❍ When doing a hysterectomy for leiomyomata, what is the chance of discovering a leiomyosarcoma?
About 0.2% to 0.3%.
❍ What are the indications of cesarean hysterectomy?
- Uterine rupture.
- An unrepairable uterine scar.
- Laceration of major uterine vessels.
- Placenta previa or accreta, unreducible uterine inversion.
- Placental abruption.
- Uterine atony unresponsive to conservative management.
- Severe cervical dysplasia or early cervical cancer may prompt a planned caesarean hysterectomy.
❍ What are the major causes of morbidity associated with cesarean hysterectomy?
Febrile morbidity and injury to the urinary tract are more common than in the nonpregnant patient, and blood
loss is usually much greater because of the hypertrophy of the uterus and the vessels. Elective cesarean hysterectomy
is known to carry an average blood loss of 1,500 mL and should therefore not routinely be done for sterilization or
for trivial indications.
❍ What other obstetrical problems may require hysterectomy?
Occasionally, septic abortion fails to respond to medical management and must be treated with hysterectomy.
Abdominal, cervical, and interstitial pregnancies may also result in hysterectomy.
❍ When is hysterectomy indicated in pelvic inflammatory disease (PID)?
Approximately 20% of patients with tubo-ovarian abscess will fail to respond to antibiotics and/or colpotomy
drainage. These women are usually treated with total abdominal hysterectomy bilateral salpingo-oophorectomy
(TAH-BSO). Ruptured tubo-ovarian abscess may also be treated with TAH-BSO. Hysterectomy may also be
recommended for patients with chronic PID who have completed childbearing, or who are not interested in
assisted reproductive technologies.
❍ When is hysterectomy indicated for cervical intraepithelial neoplasia (CIN)?
If there is persistent CIN 2 or 3 on follow-up after LEEP or conization, then re-excision is indicated. If re-excision
is found to be technically impractical, or if the woman has definitively completed childbearing, then hysterectomy
is an option, but conization should be performed for frozen section prior to the hysterectomy to look for invasive
cancer. If cancer is found by frozen section, radical hysterectomy may be appropriate; if no cancer is found, then
simple hysterectomy is appropriate.